**Surgery alone: **Amputation was classic procedure but if limb-sparing surgery can be done then preferred, especially for expendable bones such as fibula, ulna, and patella. Grafts and prosthesis are often needed. LC good but 80% have DM.

Surgery + Chemotherapy:MSK proposed neoadjvant methotrexate, vincristine, Adriamycin, and cyclophosphamide (MVAC) and then amputation. The** T-10 protocol used Methotrexate, Vincristine, Adriamycin, Bleomycin and Cisplatin with 76% RFS for CMT. The tumor response to chemotherapy is a prognostic factor and determines drugs used. **Multi-institutional Osteosarcoma Study__ __did a randomized study using the same regimen and showed the RFS was 12% for the control group and 63% for the CMT.

Randomized trials have established that neoadjuvant and adjuvant chemo help to prevent relapse or recurrence in pts with localized resectable primary tumors (Link, NEJM, 1986; JCO, 1987)

DeLaney (IJROBP 2005). Review of 41 pts with osteosarcoma that were either unresectable or had close + margins and were treated with RT. No definitive dose-response, although doses >55 Gy had higher LC (p= 0.11). RT more effective for pts with microscopic or minimal residual dz.

Radiotherapy: no primary role in the treatment of OS except for unresectable lesions near the spinal cord/vital organs or involving facial or pelvic bones. LC is poor and is used with chemotherapy. PMH showed that RT alone was not effective for LC, meaningful palliation, or useful limb. Caceres showed that pre-op RT/surgery showed some improved LC but no change in survival. Whole lung treatment has been advocated by some (15-18Gy)

Radiation Techniques

Spare 1.5-2.0 cm strip of skin in extremity if possible to prevent lymphedema.